Thursday, April 14, 2016

On Monday, the Center for Medicare and Medicaid Services
(CMS) announced
what it describes as the “largest-ever initiative to transform and improve how
primary care is delivered and paid for in America." Called the Comprehensive Primary Care Plus(CPC+)
program, the initiative is
modeled after the existing Comprehensive
Primary Care Initiative (CPCI), a 4-year pilot of advanced primary care
medical homes (PCMHs) that has been rolled out in 500 practices in 7 regions
around the country. CPCi is scheduled to
wrap up in October of this year; its participating practices will have an
opportunity to transition into the new Comprehensive
Primary Care Plus program, and many more practices will be invited and eligible
to join.

So how is the new program going to be a Plus for physicians and their patientscompared to the current
CPCi pilot and traditional fee-for-service Medicare?

For one thing, it’s Plus-sized:
CMS envisions
that the program will be available “in up to 20 regions and can accommodate up
to 5,000 practices, which would encompass more than 20,000 doctors and
clinicians and the 25 million people they serve”—a 10-fold increase in the
number of participating practices, and a nearly three-fold increase in the
number of regions where the program will be offered.

CPC+ could also be a Plus
for practices because it will offer more options. Physicians and their practices can choose
from two different participation tracks, with different care delivery
requirements and payment methodologies that reflect how advanced they are in
incorporating PCMH principles into their care delivery. Track 1 is for those
that are less advanced in fully implementing the attributes of advanced Primary
Care Medical Homes; track 2 is for more advanced practices.

CPC+ could be a Plus
for practices, especially compared to traditional FFS Medicare, because it
gives them more Medicare dollars upfront, which will be in addition to the amounts they get reimbursed for individual
patient encounter (evaluation and management service) codes:

Track 1 practices will receive an average
risk-adjusted payment of $15 per beneficiary per month; they can earn another $2.50
PBPM if they do well on metrics of quality and utilization.

Track 2 practices would receive an average
risk-adjusted PBPM payment of $27 and up to $100 PBPM for the highest risk
patients); they can earn an additional $4 PBPM based on performance.

However, CPC+ also adds financial risk to the equation. If
track 1 practices do not meet their performance metrics, they will have to
repay Medicare for the $2.50 PBPM incentive payment. If track 2 practices don’t meet their
metrics, they would repay Medicare for the $4.00 PBPM incentive payment.

My back-of-the envelope calculation shows how much more in
upfront Medicare money this could mean for participating practices. A track 1 practice with 1000 Medicare
beneficiaries would on average receive $15,000 in monthly (PBPM) payments, or
$180,000 over 12 months. If they are able
to keep the $2.50 PBPM incentive payment, it would be $17,500 per month, or
$210,000 for the year. Track 2 practices with 1000 Medicare patients would on average
get $27,000 per month in PBPM advance payments, or $324,000 for a year; with
the additional $4 PBPM incentive payment, it would be $31,000 per month, or
$372,000 for the year.

For track 1 practices, these upfront PBPM payments would be in addition to getting 100% of their
usual Medicare FFS payments for office visits and procedures billed a la carte.

It’s more complicated, though, for track 2 practices,
because their upfront PBPM payments will be offset by reduced payments for
separately-billed office visits and other evaluation and management
services. In an editorial published in
the Journal of the American Medical Association, CMS officials explain
how this will work:

“Track 2
practices will receive an up-front payment of a portion of their expected
evaluation and management claims on a per capita basis, independent of
claims. Subsequent claims for evaluation
and management services will be paid at a commensurately reduced rate. As the
ratio of the hybrid payment is titrated up during the model, the reduced
payment for billed evaluation and management services will pay practices for
the marginal cost of an office visit, making practices ‘incentive neutral’ to
the mode of care delivery and allowing them the flexibility to deliver care in
the manner that best meets patients’ needs—without being tethered to the
20-minute office visit. Practices might offer non–face-to-face visits (e.g.,
electronic or telephone), offer visits in alternate locations, or simply
provide longer office visits for patients with complex needs. CMS will monitor
practices to ensure delivery of quality health care.”

Their non-evaluation and
management services would continue to be paid 100% of the usual rates.

So for Track 2 practices
especially, it comes down to them deciding whether having a big pot of “bird-in-the-hand”
upfront PBPM payments, and the financial support and flexibility it provides to
manage things without being “tethered” to visits, is worth being paid
commensurately less when they have to bill separately for a visit.

Or, to put it another way, do
they prefer getting more of their revenue upfront from risk-adjusted capitation
and less downstream from FFS billings?

The Comprehensive Primary Care
Plus program could also be a Plus for
practices by giving them access to extra support and revenue from payers other
than Medicare: CMS will be seeking formal commitments from non-Medicare payers
to support participating practices, and will only launch the program in
localities where there is such a commitment from enough payers.

The CPC+ program could also be a
Plus for participating physicians and
their practices because it should give them a big leg-up in qualifying for
higher payments under the new MACRA law, either as an Alternative Payment Model
(APM) or under the Merit-based Incentive Payment System (MIPS) created by the legislation.

Finally, the Comprehensive
Primary Care Plus program would also be a Plus
for patients, if it truly achieves its goals of
providing practices with the “financial resources [needed] to implement the
processes and hire the staff needed to deliver the 5 primary care functions:
(1) access and continuity, (2) risk-stratified care management, (3) planned
care for chronic conditions and preventive care, (4) patient and caregiver
engagement, and (5) comprehensiveness and coordination of care.”

ACP, in a supportive statement,
noted several features of the program that will be critically important
for it to be successful in meeting the goals of supporting and strengthening
primary care:

·We strongly support the goal of ensuring that
practices in each track will be able to build capabilities and care processes
to deliver better care, which will result in a healthier patient population.

·We agree with the need for payment redesign that
offers the ability for greater cash flow and flexibility for primary care
practices to deliver high quality, whole-person, patient-centered care and
lower the use of unnecessary services that drive total costs of care.

· We
support the critical importance of obtaining commitments from other
(non-Medicare) payers to join with Medicare to support CPC+ practices.

·We are encouraged that CPC+ will provide
practices with a robust learning system, as well as actionable patient-level
cost and utilization data, to guide their decision making.

Yet ACP’s statement concluded with a cautionary note: “The success of the Comprehensive Primary
Care Plus program will depend on Medicare and other payers providing physicians
and their practices with the sustained financial support needed for them to
meet the goal of providing comprehensive, high value, accessible, and
patient-centered care, with realistic and achievable ways to assess each
practices’ impact on patient care. The
College is committed to working with CMS on the details of implementation to
ensure that the program is truly able to meet such requirements of success.”

While the verdict is still out, the Comprehensive Primary Care Plus initiative truly is a big deal for
primary care, potentially offering a way for practices that embrace the PCMH
model—as long championed by ACP—to get more upfront payments from Medicare and
other payers to help them make their practices more accessible and responsive
to the needs of their patients, while accepting a degree of financial risk for
achieving the desired results.

Today’s questions: Do
you think that the Comprehensive Primary Care Plus program will truly be a Plus for primary care physicians, their
practices, and their patients? Would you
consider having your practice participate?